Actures in hospital - NICE Pathways
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Pelvic fr
fractures
actures in hospital
NICE Pathways bring together everything NICE says on a topic in an interactive
flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/trauma
NICE Pathway last updated: 17 June 2019
This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.
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1 Person with suspected pelvic fracture in hospital
No additional information
2 Haemorrhage control in hospital
For first-line invasive treatment of active arterial pelvic bleeding, use:
interventional radiology if emergency laparotomy is not needed for abdominal injuries
pelvic packing if emergency laparotomy is needed for abdominal injuries.
3 Imaging in hospital
Use CT for first-line imaging in people aged 16 and over with suspected high-energy pelvic
fractures.
For first-line imaging in people under 16 with suspected high-energy pelvic fractures:
use CT rather than X-ray when CT of the abdomen or pelvis is already indicated for
assessing other injuries
consider CT rather than X-ray when CT of the abdomen or pelvis is not indicated for
assessing other injuries.
Use clinical judgement to limit CT to the body areas where assessment is needed.
Do not log roll people with suspected pelvic fractures before pelvic imaging unless:
an occult penetrating injury is suspected in a person with haemodynamic instability
log rolling is needed to clear the airway (for example, suction is ineffective in a person who
is vomiting).
When log rolling, pay particular attention to haemodynamic stability.
4 Pain relief in hospital
High-energy pelvic fractures
For patients with suspected high-energy pelvic fractures, use intravenous morphine as the first-
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line analgesic and adjust the dose as needed to achieve adequate pain relief.
If intravenous access has not been established, consider the intranasal route for atomised
delivery of diamorphine or ketamine1.
Consider ketamine in analgesic doses as a second-line agent.
Low-energy pelvic fractures
For recommendations on the initial pharmacological management of pain in adults with
suspected low-energy pelvic fractures, see what NICE says on hip fracture.
5 Removal of pelvic binders in hospital
For people with suspected pelvic fractures and pelvic binders, remove the pelvic binder as soon
as possible if:
there is no pelvic fracture, or
a pelvic fracture is identified as mechanically stable, or
the binder is not controlling the mechanical stability of the fracture, or
there is no further bleeding or coagulation is normal.
Remove all pelvic binders within 24 hours of application.
Before removing the pelvic binder, agree with a pelvic surgeon how a mechanically unstable
fracture should be managed.
6 When to transfer
Immediately transfer people with haemodynamic instability from pelvic or acetabular fractures to
an MTC for definitive treatment of active bleeding.
Transfer people with pelvic or acetabular fractures needing specialist pelvic reconstruction to an
MTC or specialist centre within 24 hours of injury.
Immediately transfer people with a failed closed reduction of a native hip joint to a specialist
centre if there is insufficient expertise for open reduction at the receiving hospital.
1
At the time of publication (February 2016), neither intranasal diamorphine or intranasal ketamine had a UK
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7 Documentation
See Trauma/fractures in hospital /documentation
marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full
responsibility for the decision. Informed consent should be obtained and documented. See the General Medical
Council's Prescribing guidance: prescribing unlicensed medicines for further information.
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Glossary
ASIA
American Spinal Injury Association
BIS
Bispectral Index
Delayed primary amputation
amputation when there is time to delay decision but reconstructive surgery is not involved in the
decision
EEG
electroencephalography
eFAST
extended focused assessment with sonography for trauma
FAST
focused assessment with sonography for trauma
RSI
rapid sequence induction
TARN
trauma audit and research network
MRC
Medical Research Council
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MTC
major trauma centre
MTCs
major trauma centres
NSAIDs
non-steroidal anti-inflammatory drugs
PACS
picture archiving and communication system
Sources
Major trauma: assessment and initial management (2016) NICE guideline NG39
Fractures (complex): assessment and management (2016 updated 2017) NICE guideline NG37
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
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and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Medical technologies guidance, diagnostics guidance and interventional procedures
guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
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make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in
their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
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